OMENTAL TRANSPOSITION IN CHRONIC SPINAL-CORD INJURY

The results of omental transposition in chronic spinal cord injury hav e been reported in 160 patients operated upon in the United States, Gr eat Britain, China, Japan, India and Mexico, with detailed outcomes re ported in few studies. Recovery of function to a greater degree than e xpected by natural history has been reported. In this series, 15 patie nts with chronic traumatic spinal cord injury (>1.5 years from injury) underwent transposition of pedicled omentum to the area of spinal cor d injury. Of the first series of four patients who were operated upon in 1988, one died, one was lost to follow-up and two were followed wit h sequential neurological examinations and Magnetic Resonance Imaging (MRI) scans preoperatively, at 1 year post injury and 4 1/2 years post injury. Another 11 patients were operated in 1992 and underwent detai led neurological and neurophysiological examinations and had MRT scans preoperatively and every 4 months for at least 1 year after surgery. All patients completed a detailed self-report form. Of the total of 13 operated patients in both series followed for 1-4 1/2 years, six repo rted some enhanced function at 1 year and five of these felt the chang es justified surgery primarily because of improved truncal control and decreased spasticity. MRI scans showed enlargement of the spinal cord as compared to preoperative scans in seven patients. Increased T2 sig nal intensity of the spinal cord was found by 1 year after surgery in eight of 13 operated patients. Neurophysiological examinations of 11 p atients in the second series agreed with self-reports of increases or decreases in spasticity (r = 0.65, P < 0.03). Somatosensory evoked pot entials and motor evoked potentials at 4 month intervals up to 1 year in these patients showed no change after surgery. Neurological testing , using the American Spinal Injury Association (ASIA) and Internationa l Medical Society of Paraplegia (IMSOP) international scoring standard s, failed to show any significant changes when the I-year post operati ve examination was compared to the first preoperative examination exce pt for decreased sensory function after surgery which approached stati stical significance. When the 11 patients in the second series were co mpared to eight non-operated matched patients, followed for a similar length of time, no significant differences were found. Complications e ncountered in the operated patients from both series included one post operative death from a pulmonary embolus, one postoperative pneumonia, three chronic subcutaneous cerebrospinal fluid (CSF) fistulae requiri ng wound revision, and one patient who developed biceps and wrist exte nsor weakness bilaterally requiring graft removal. We conclude that th e omental graft remains viable over time and this operation can induce anatomical changes in the spinal cord as judged by MRI. Some patients reported subjective improvement but this was not supported by objecti ve testing. We, therefore, find no justification for further clinical trials of this procedure in patients who have complete or sensory inco mplete lesions. Further testing in motor incomplete patients would see m appropriate only with compelling supportive data.